By KORYDON SMITH

Professor of architecture and associate director, Community for Global Health Equity

Reprinted from The Conversation

Two seemingly unrelated national policy debates are afoot, and
we can’t adequately address one unless we address the
other.

Health care reform has been the hottest topic. What to do about
America’s aging infrastructure has been less animated but may
be more pressing.

Yet even as cracks in America’s health system and
infrastructure expand, political divides between parties and within
parties have stalled efforts to develop policies and implement
solutions. Problematically, debates over health care reform and
infrastructure projects remain separate.

As a professor of architecture who also studies health equity
— the establishment of systems, laws and environments that
promote fair access to health care — I believe we have reason
to be concerned.

What if a solution to bridging both the political and sectoral
divides between health care and infrastructure was, literally, a
bridge? Sure, bridges are core elements of infrastructure, but what
do bridges have to do with health care?

As it turns out, a lot.

Abroad, substandard infrastructure kills

We have seen the negative effects of poor infrastructure most in
poverty-stricken countries.

In October 2016, Haiti saw the importance of bridges. Still
reeling from the devastating 2010 earthquakes, the poorest country
in the Americas was struck by Hurricane Matthew.

Torrential rains led to contaminated food and water supplies,
and, subsequently, a cholera outbreak. They also washed out the
bridge over the River La Digue. The collapse broke a link in the
primary highway connecting the capital of Port-au-Prince to the
southern peninsula of Haiti, the area worst hit by Matthew.

Without road access, medical supplies, water and food rations,
community-education programs, and equipment to repair water and
sanitation systems could not be delivered. Disease spread
further.

Disasters are not the only situations where fractures in
infrastructure impact health.

In Uganda — a country with a high prevalence of
preventable and treatable illnesses, such as respiratory infections
— the “last mile” of the supply chain is a matter
of life and death. While effective, low-cost treatments exist, the
leading causes of childhood mortality include pneumonia, malaria
and diarrheal diseases.

As in the U.S., rural children in Uganda are at a greater risk
of death than those living in cities. In fact, children living in
the rural northeast region of Karamoja die at more than double the
rate of children living in the capital region of Kampala. The
health literacy of parents is one factor; access to health
facilities is another.

Improving infrastructure, improving health

New research from UB reveals something more striking about the
role of supply chains: Many preventable deaths are occurring simply
because local clinics and kiosks run out of supplies.

“In some districts,” according to Biplab
Bhattacharya, a PhD student on the team, “only 50 percent of
health facilities have regular supplies of ACTs,” a primary
treatment for malaria, “and many were vulnerable to
stock-outs between deliveries.”

Li Lin, the lead researcher, also noted that retailers struggle
to keep adequate supplies of inexpensive yet lifesaving
over-the-counter therapies, like oral rehydration solutions for
children with acute diarrhea.

This research comes from a rather unexpected partnership between
scholars in industrial and systems engineering who worked with
partners in the Clinton Health Access Initiative and the Ministry
of Health in Uganda. The work illustrates the value of
nontraditional partnerships in identifying problems and finding
solutions.

Future public health efforts in Uganda, therefore, may focus not
on the development of vaccines or treatments but on infrastructure,
such as information management systems, which can predict
stock-outs before they happen, and improved roads, which can enable
faster delivery of supplies.

U.S. vulnerable, too

While robust technologies shore up America’s supply
chains, including the delivery of medications and other health
supplies, other areas of infrastructure are not only deteriorating
but also do not address imminent, or recurring, public health
threats. I fear America is slowly returning to its status in the
early 19th century as a developing nation.

In the late 1800s and early 1900s, cities throughout the U.S.
eradicated the spread of waterborne diseases, such as typhoid, by
investing in water and sanitation improvements.

However, as the Flint water crisis of 2014 illustrated,
America’s infrastructure presents one of the greatest threats
to the health of Americans. Michael Beach, associate director for
healthy water at the Centers for Disease Control and Prevention,
stresses that “the U.S. commitment to bring safe water and
sanitation to the country” in the 19th and 20th centuries
“was a great first step, but we can’t let our guard
down; germs adapt.”

Beach adds that outdated infrastructure has contributed to an
estimated 240,000 water main breaks each year and, if not upgraded,
can “expose users to sewage, pathogens and other
contaminants.”

According to the 2017 Infrastructure Report Card, the average
U.S. bridge is 43 years old and there are, on average, 188 million
trips each day across structurally deficient American bridges. With
each passing car and each passing day, these bridges become more
life-threatening.

According to the World Bank, approximately 17 percent of the
U.S. GDP goes to health care spending, more than any other country.
By contrast, spending on transportation infrastructure amounts to
less than 0.4 percent of the country’s GDP. Moreover, during
the past decade, health spending has grown, while infrastructure
spending has constricted despite the need for upgrades.

While political debates often tie public works projects to
economic development, and health care policies to human health,
infrastructure and health care intersect. Both have economic and
health implications. Civic infrastructures — including the
seemingly unrelated sectors of energy, transportation and housing
— are as important to the health care toolkit as vaccines,
hospital beds and surgical units.

For example, over half a million children under the age of five
die every year worldwide due to air pollution.
Transportation-related smog is one contributor, which is why cities
with the best transportation systems often have a lower incidence
of respiratory diseases. Investments in transit not only improve
convenience and access, but also reduce governments’ and
individuals’ burden of treating otherwise preventable
diseases.

Of course, infrastructure spending is not immune to political
roadblocks. Questions regarding how to resource a plan, which
projects to prioritize and how to award contracts present
challenges. New approaches to funding might be legislation on
improving health infrastructure, like the construction and
renovation of rural hospitals, or the development and purchase of
medical technologies for specialized urban health centers, or the
training of community-based health professionals who can work
across sectors.

We might then build outward, ensuring better transportation to
these hospitals, stronger paths of communication from major health
centers and the integration of neighborhood services across health,
education and transportation sectors. We could also shore up rural
hospitals, structurally and financially, as, according to the
Chartis Center for Rural Health, 80 have closed across the U.S.
since 2010. This is despite higher levels of patient satisfaction
than their urban counterparts.

Moving the health care debate to a discussion on infrastructure
might accomplish two vital needs. It might advance the health care
debate by both walking away from the current gridlock and
approaching the destination from a fresh perspective. It also might
advance public health by making America’s highways,
neighborhoods and water systems safer, mediating the risks of
health care and bridge collapses.

READER COMMENT

Very well-done Professor Korydon Smith! Perhaps your initiative
with this article will spark an interdisciplinary task force
dialogue within the academic 'families' within UB, as well as
beyond.

I would be interested to hear from faculty and students as to
what their thoughts are after reading this article by Professor
Smith.